Physical and Sexual Intimate Partner Violence and Psychological Distress Among Injection Drug Users in Baltimore

Abstract

Substance use and intimate partner violence (IPV) are both associated with psychological distress. This study examines the association between IPV victimization and psychological distress among people who inject drugs (PWID) to inform intervention programs aimed at reducing the violence and associated negative outcomes. As part of the 2012 National HIV Behavioral Surveillance System survey, 592 PWID were recruited in Baltimore by respondent-driven sampling. Study variables included sociodemographic variables, drug use characteristics, IPV, and psychological distress. Multivariable linear regression models were used to assess the association between IPV and psychological distress in men and women who inject drugs. Nearly 10% of participating PWID reported IPV during the past12 months. Sexual IPV was more common than physical IPV for women, while men reported physical IPV more frequently. Men and women PWID who experienced IPV had higher psychological distress than those without such a history. For men who inject drugs but not for women, drug use characteristics explained the association between IPV and psychological distress. These findings suggest that addressing the experience of IPV among women PWID may be important for improving their mental health.

Introduction

People who inject drugs (PWID) are a marginalized and stigmatized population with unique psychosocial needs and health problems. Several studies have indicated that psychological distress is more common in PWID than in the general population (Golub et al. 2003; Scott et al. 2016). Psychological distress is an indicator of mental health status defined as “a state of emotional suffering characterized by symptoms of depression (e.g., lost interest, sadness, hopelessness) and anxiety (e.g., restlessness, feeling tense)” (Bessaha 2017; Drapeau et al. 2012). In the 2012 national survey on drug use and health, 41% (8.4 million) of adults with past-year substance use disorders (SUDs) in the United States had experienced psychological distress (SAMHSA 2013). Psychological distress may negatively impact PWID's ability to engage in self-care and protective health behaviors, and increase high-risk injections, drug use, and sexual behaviors that may result in overall poorer functioning, decreased social functioning, homelessness, incarceration, disability, and worse quality of life (Buckley 2005; Cleary et al. 2008).

There is also a link between SUDs and intimate partner violence (IPV) (Clark et al. 2001; McKetin et al. 2014). According to a growing body of literature, the prevalence of IPV is higher among people with SUDs and their partners (Singer 2003, 2016; Stuart et al. 2009b). People with SUDs may have up to 8–10 times greater risk for IPV victimization than those without SUDs (Pickard and Fazel 2013). Although it is well established that IPV in both men and women is associated with psychological distress (Turner et al. 2020), drug use and IPV may have synergistic effects on psychological distress among PWID; however, this effect may differ based on gender. For instance, victimized men are less likely to experience depressive symptomatology and require medical services for their injuries than victimized women (Tjaden and Thoennes 2000). Victimized women are also more likely to miss work and use mental health services than their victimized male counterparts (Stuart et al. 2009b). Although IPV among men is less common, often of lower severity, and associated with less harm (Hines and Douglas 2010), a considerable proportion of men in high-income countries have reported experiencing physical IPV or sexual assault (Hines and Douglas 2016; Iverson et al. 2013; Walters et al. 2013).

Despite the finding that IPV is consistently associated with both psychological distress and SUDs in the general population (Sullivan et al. 2009), little is known about the association between IPV, drug use characteristics, and psychological distress among PWID—a key population who may experience other forms of social vulnerability. A better understanding of the role of IPV as a risk factor for psychological distress of PWID is therefore crucial to inform future health interventions and programs for this vulnearble population. The purpose of the present study is to examine the association between IPV and psychological distress in a sample of PWID in Maryland. Given gender differences in exposure and sensitivity to violence (Chermack et al. 2000; Cottler et al. 1992) and in psychological distress (Astin et al. 2003; Kinner et al. 2009; Williams and Frieze 2005), we examined these associations by gender.

Methods

Participants

Participants were recruited using respondent-driven sampling (RDS), a chain-referral sampling method commonly used to identify hard-to-reach or hidden populations (Heckathorn 2002). This recruitment method was tailored for PWID as a hidden population to maximize participation and sample representativeness{German, 2014 #74}. Eligible participants were 18–50 years of age, had injected drugs in the past 12 months, lived in Baltimore, and could complete the interview in English. Participants who met eligibility criteria were enrolled and provided informed consent before completing the study procedures. After survey completion, each study participant was offered coupons for peer recruitment. The participants were compensated $50 for completing the survey and an additional $10 if they referred eligible peers to enroll in the study. By conducting several waves of recruitment, the sample achieved a stable composition, independent of the initial seeds used to recruit peers (Heckathorn 1997, 2002; Villanti et al. 2012).

Design and setting

Data for this study were obtained from the 2012 wave of the National HIV Behavioral Surveillance System (NHBS) survey for PWID in a large Maryland city (Gallagher et al. 2007). The NHBS conducted behavioral surveys and voluntary HIV testing across 25 urban areas in the United States, targeting several key populations: men who have sex with men, high-risk heterosexual adults, and injection drug users (Gallagher et al. 2007). The design and methods of the NHBS survey cycle conducted among PWID has been described in detail elsewhere (Lansky et al. 2007; Villanti et al. 2012).

Procedure

Trained public health interviewers administered a standardized questionnaire to participants in face-to-face structured interviews using handheld data collection devices (Sionean et al. 2014). All interviews were conducted in a private and confidential location. Each interview lasted about 45 min. The data were anonymized using unique study IDs assigned sequentially to each participant's questionnaire.

The NHBS-PWID study protocol and all local materials were approved by Institutional Review Boards at the Johns Hopkins Bloomberg School of Public Health and the Maryland Department of Health.

Measures

Study variables included demographic characteristics, sexual behaviors, drug use characteristics, physical or sexual IPV, and psychological distress (see Appendix Table A1 for an overview of measures).

Sociodemographic characteristics

Age was considered a continuous variable. Four individuals who identified as transgender were not included in the analysis due to the small cell size. Race/ethnicity was categorized as white Non-Hispanic, African American, Non-Hispanic, Hispanic, and other. Education was recoded as less than high school level, having a high school degree or GED, or receiving additional schooling beyond high school or GED. For this analysis, past-year income was categorized as <$10,000, $10,000 to $34,999, or ≥$35,000. An income of less than $10,000 in the past year was used as an approximation of poverty for a single person, in line with federal guidelines for 2006 [U.S. Department of Health and Human Services (DHHS) 2015]. Sexual orientation was defined as heterosexual, bisexual, or homosexual. Marital status was recoded as never married; living together as married; or being separated, widowed, or divorced. Respondents were also classified as unemployed, employed, retired, or unable to work. Participants were asked to report any history of homelessness in the past 30 days and in the past 12 months. They were also asked to recall any instances of exchanged sex in the past 12 months, defined as engaging in sexual behavior in exchange for money, drugs, shelter, and so on.

Drug use behaviors

Assessment of past 12-month injection drug use included questions on frequency of injection and age of initiating injection. Participants also reported on frequency of crack use as a noninjection drug during the past 12 months.

Physical and sexual IPV

A measure of physical or sexual IPV in the past 12 months was adapted from the national intimate partner and sexual violence survey questionnaire [Centers for Disease Control and Prevention (CDC) 2010]. Specifically, participants were asked whether they had been slapped, punched, shoved, kicked, shaken, or otherwise physically hurt in the past 12 months by a partner (physical violence), and whether they were forced or pressured to have vaginal, oral, or anal sex by a partner (sexual violence).

Psychological distress

The Kessler Psychological Distress Scale (K6) was used to assess nonspecific psychological distress along the depression/anxiety spectrum (Kessler et al. 2002). The K6 is a screening scale for mental illness developed for use in health risk appraisal surveys (Cunningham and Paradies 2012), such as the CDC's Annual National Household Survey on Drug Abuse (NSDUH). Participants indicated how often in the past 30 days they felt: (1) nervous, (2) hopeless, (3) restless or fidgety, (4) sadness or so depressed that nothing could cheer them up, (5) that everything was an effort, and (6) feel down on oneself, no good, or worthless. Response options for each of the five items were: 0 “none of the time,” 1 “a little of the time,” 2 “some of the time,” 3 “most of the time,” or 4 “all of the time.” Studies have demonstrated excellent internal consistency (Cronbach's alpha = 0.89) for this scale (Kessler et al. 2002; Stolk et al. 2014). Responses were summed over the six questions to produce a total score that could range from 0 to 24, with higher scores indicating greater psychological distress. We treated the K6 total score as a continuous variable in analyses. The total score was interpreted as the “one unit increasing in independent variable will increase a mean score of Kessler 6 as dependent variable.” The cutoff point of ≤13 was considered as serious mental illness in accordance with the use of this score as indicating high or very high risk of psychological distress in prior studies (Kessler et al. 2003a; Prochaska et al. 2012).

Statistical analysis

Descriptive statistics for the sample were summarized by gender and type of violence experienced (sexual or physical violence vs. none) and compared by group using independent samples' t-tests and Pearson's chi-square tests. A series of multiple linear regression models were used to assess the association between psychological distress with IPV. The first model estimated the unadjusted association between psychological distress and violence by partner in the past 12 months. The second model adjusted for demographic variables, and in the final model, drug-related factors were added as covariates to estimate adjusted relationships. All models were stratified by gender. Data analysis was conducted using Stata 14.00.

Results

A total of 601 individuals participated in the study; nine participants (1.5%) who did not complete the full questionnaire for any reason were excluded from the analysis. Data of 592 participants were included in the analyses: 28.5% (n = 169) were women; 71.5% (n = 423) were men. Approximately three quarters of the total sample (72.2% of women vs. 77.1% of men) were non-Hispanic black, and about half were unemployed (53.2% of men compared with 55.3% of women). Key study characteristics are presented separately by gender in Table 1.

Table 1.

Demographic, Socioeconomic, and Drug-Related Factors of the Study Participants

	Total sample		Males	Females
	N = 592		n = 423	n = 169
	N or M	% or SD	N or M	% or SD	N or M	% or SD	t or, Fisher's or χ²
Demographic factors
Age	49.2	10.3	50.3	10.5	46.5	9.2	−4.3^**
Race/ethnicity
Non-Hispanic white	114	19.3	80	18.9	34.0	20.12	3.92
Non-Hispanic black	448	75.7	326	77.1	122.0	72.19
Hispanic	8	1.4	4	0.95	4.0	2.37
Other	22	3.7	13	3.07	9.0	5.33
Sexual orientation
Heterosexual	506	85.8	388	91.9	118.0	70.2	46.5^**
Homosexual	14	2.4	5	1.2	9.0	5.4
Bisexual	70	11.9	29	6.9	41.0	24.4
Marital status
Never married	350	59.1	252	59.6	98.0	58	9.02
Living together as married	61	10.3	41	9.7	20.0	11.8
Separated	51	10.3	32	7.6	19.0	11.2
Divorced	95	16.1	77	18.2	18.0	10.6
Widowed	35	5.9	21	5	14.0	8.3
Education
Below grade 12	229	38.7	158	37.4	71.0	42	1.24
Grade 12	250	42.2	181	42.8	69.0	40.8
Above grade 12	113	19.1	84	19.9	29.0	17.2
Socioeconomic factors
Employment situation
Unemployment	318	53.7	225	53.2	93.0	55.03	0.25
Employment	50	8.5	37	8.8	13.0	7.7
Retired or unable to work	224	37.8	161	38.1	63.0	37.3
Income
<$10,000 (years)	182	31.5	124	31.1	58.0	35.2	3.18
10,000–34,999 $ (years)	170	29.5	118	28.6	52.0	31.5
≥35,000 $ (years)	225	39.0	170	41.3	55.0	33.3
Homeless
Currently	151	25.5	122	28.8	29.0	17.2	8.7^**
Past 12 months	260	43.9	200	47.3	60.0	35.5	6.8^**
Drug-related factors
Years of injection drug use	26.2	14.2	28.4	14.2	20.5	12.3	−6.8^**
Age of initiating injection drug use	23.1	9.4	21.9	8.8	26.1	10.1	4.7^**
Frequency of injection, past 12 months
More than once a day	453	77.2	315	75.2	138.0	82.1	3.3^*
Once a day or less	134	22.8	104	24.8	30.0	17.9
Often used crack, past 12 months
Never	153	43.84	102	41.98	51	49.04	3.82
More than once a day	145	41.55	109	44.86	35.0	33.65
Once a week or less	51	14.61	32	13.17	18.0	17.31
Exchange sex, past 12 months
Yes	167	28.2	110	26	57.0	33.7	0.1
No	425	71.8	313	74	112.0	66.3
Physical partner violence, past 12 months	53	9.0	35	8.4	18.0	10.7	0.8
Sexual partner violence, past 12 months	22	3.8	10	2.4	12.0	7.1	7.5^**
Psychological distress	10.1	5.6	9.5	5.5	11.4	5.7	3.7^**

p < 0.05, ^**p < 0.01.

Mean years of injection drug use was significantly higher among men than among women (14.2 years vs. 12.3 years, t = 4.71, p < 0.01) and women were significantly older at age of first injection than men (26.1 years old vs. 21.9 years old, t = 6.76, p < 0.01). There were also significant differences among men and women in sexual orientation (70.2% of women and 91.9% of men were heterosexual), income (35.2% of women and 31% of men earned less than $10,000 per year), age at the time of study (46.5 years in women vs. 50.3 years in men), current homelessness (17.2% in women vs. 28.8% in men), and past-year homelessness (35.5% in women vs. 47.3% in men). The overall prevalence of crack use among participants was 56.1% (95% confidence interval: 50.8–61.3) and did not differ by gender.

Women were significantly more likely to report past-year sexual partner violence (SPV) than men (7.1% vs. 2.4%, χ² = 7.48, p < 0.01), but physical violence was not significantly different by gender. In addition, women reported a significantly higher mean psychological distress score than men (11.4 vs. 9.5, range score = 0–24, t = 3.68, p < 0.01) (Table 1).

Table 2 presents participant characteristics stratified by type of IPV experienced. Participants who reported physical partner violence or SPV in the past year were significantly younger on average than those who did not (mean 42.8 and 42.3 compared with 49.8 and 49.4, respectively; F = 4.6 and 3.18, p < 001). Sexual orientation among the participants was significantly associated with IPV (χ² = 6.06, p < 0.05). Participants who experienced any IPV had significantly lower income compared with those who did not experience IPV in the past year (χ² = 7.3, p < 0.05). Non-Hispanic white participants reported significantly more physical or sexual partner violence than other races (34.3% vs. 17.5%, χ² = 10.3, p < 0.01). There were no significant racial differences in SPV victimization. The mean psychological distress score was significantly higher among participants who experienced any IPV than among participants who reported no past-year experience of IPV (13.2 vs. 9.7, t = −5.2, p < 0.05, range = 0–24) (Table 2).

Table 2.

Demographic, Socioeconomic, and Drug-Related Factors of Study Sample Experiencing Physical and Sexual Violence by Partner in the Past 12 Months

	Intimate partner violence (physical or sexual)					Physical violence					Sexual violence
	Yes		No			Yes		No			Yes		No
	n = 61		n = 533			n = 53		n = 535			n = 22		n = 566
	N or M	% or SD	N or M	% or SD	t or χ²	N or M	% or SD	N or M	% or SD	t or χ²	N or M	% or SD	N or M	% or SD	t or χ²
Demographic factors
Age	61	42.9	533	50.0	5.0^**	53	42.8	535	49.8	4.6^**	22	42.3	566	49.4	3.2^**
Gender
Female	18	34.0	150	28.1	0.8	18	34.0	150	28.1	0.8	12	54.6	156	27.7	7.5^*
Male	35	66.0	383	71.9		35	66.0	383	71.9		10	45.5	408	72.3
Marital status
Never married	32	60.4	315	58.9	0.9	32	60.3	315	58.9	0.7	11	50.0	336	59.4	0.3
Living together as married	7	13.2	163	10.3		7	13.2	55	10.3		1	4.6	169	10.8
Separated, widowed, divorced	14	26.4	55	30.8		14	26.4	165	30.8		10	45.5	61	29.9
Sexual orientation
Heterosexual	46	75.4	460	86.6	6.06^*	39	73.5	462	86.7	6.88^*	15	68.2	486	86.2	8.9^*
Homosexual	2	3.3	14	2.6		2	3.7	13	2.4		0	0	15	2.7
Bisexual	13	21.3	57	10.7		12	22.6	58	10.9		7	31.8	63	11.2
Education
Below grade 12	19	31.2	211	39.6	2.16	18	33.9	209	39.1	0.67	7	31.8	220	38.9	1.01
Grade 12	27	44.3	223	41.8		23	43.4	224	41.9		9	40.9	238	42.1
Above grade 12	15	24.6	99	24.6		12	22.6	102	19.1		6	27.2	108	19.1
Race/Ethnicity
Non-Hispanic white	21	34.4	93	17.5	10.26^**	17	32.08	97	18.1	0.72^*	9	40.9	105	18.6	7.4^*
Non-Hispanic black	38	62.3	412	77.3		34	64.1	410	76.7		13	59.1	431	76.2
Hispanic and other	2	3.2	28	5.3		2	3.7	28	5.2		0	0.0	30	5.3
Socioeconomics factors
Employment situation
Unemployment	41	67.2	279	52.4	5.3	37	69.8	281	52.5	5.8	14	63.6	304	53.7	1.0
Employment	5	8.2	45	8.4		3	5.6	47	8.8		2	9.1	48	8.5
Retired or unable to work	15	24.6	209	39.2		13	24.5	207	38.7		6	27.3	214	37.8
Income level
<$10,000 (years)	29	48.3	153	29.5	10.1^*	25	48.08	157	30.1	7.2^*	11	50.0	171	31.0	3.6
10,000–34,999 $ (years)	10	16.7	161	31.0		10	19.2	156	29.9		4	18.2	162	29.4
≥35,000 $ (years)	21	35	205	39.5		17	32.6	208	39.9		7	31.8	218	39.6
Homeless
Currently	27	44.3	125	23.5	12.4^**	24	45.3	127	23.7	11.7^**	13	59.1	138	24.4	13.4^**
Past 12 months	40	65.6	225	42.1	12.7^**	35	66.0	225	42.1	11.2^**	17	77.3	243	42.9	10.1^**
Drug-related factors
Years of injection drug use	61	19.6	535	26.9	4.3^**	53	19.5	535	26.8	4.0^**	22	19.6	566	26.4	2.4^*
Age of initiating injection drug use	61	23.3	535	23.0	−0.2	53	23.4	535	23.0	−0.4	22	22.7	566	23.0	0.2
Frequency of injection, past 12 months
More than once a day	49	80.3	406	76.9	0.4	42	79.3	412	77.01	0.1	15	68.2	439	77.6	1.06
Once a day or less	12	19.7	122	23.1		11	20.8	123	22.9		7	31.8	127	22.4
Often used crack, past 12 months
Never	6	13.3	45	14.8	1.2	5	12.2	46	14.9	1.02	1	6.7	50	15.0	1.01
More than once a day	22	48.9	123	40.5		20	48.7	125	40.6		6	40.0	139	41.6
Once a week or less	17	37.8	136	44.7		16	39.02	137	44.5		8	53.3	145	43.4
Exchange sex, past 12 months
Yes	26	42.6	141	29.6	7.0^*	22	41.5	145	27.2	4.8^*	14	63.6	153	27.1	13.8^**
No	35	57.4	390	73.5		31	58.4	388	72.8		8	36.4	411	72.9
Psychological distress	61	13.2	524	9.7	−5.2	53	13.2	531	9.74	− 4.8	22	13.5	562	9.9	−3.1^*

p < 0.05, ^**p < 0.01.

Table 3 shows the results of three regression models by gender, with IPV as the independent variable and psychological distress as the outcome. In Model 1, which was the unadjusted model, experiencing IPV was significantly associated with higher psychological distress for both females and males (4.88-point and 2.71-point mean, respectively). In Model 2, which adjusted for socioeconomic factors (age, sexual orientation, ethnicity, educational level, income level), IPV showed an independent effect on psychological distress in women (B = 4.58, p < 0.001) as well as men (B = 1.88, p < 0.05). In Model 3, which also adjusted for drug-related factors (years of injection, injection frequency in the past 12 months, often having used crack in the past 12 months, or having exchanged sex in the past 12 months) the association between IPV and psychological distress remained significant for women (B = 4.94, p < 0.001) but not for men (B = 0.90, p > 0.05) (Table 3).

Table 3.

Adjusted Association Between Violence by Intimate Partner and Psychological Distress in Past 12 Months in Women and Men (N = 592)

	Model 1^†				Model 2				Model 3
	Female		Male		Female		Male		Female		Male
	B	95% CI	B^†	95% CI	B	95% CI	B^†	95% CI	B^†	95% CI	B^†	95% CI
Violence	4.88^***	2.31 to 7.45	2.71^**	0.95 to 4.48	4.58^**	1.92 to 7.23	1.88^*	0.10 to 3.66	4.94^**	1.66 to 8.23	0.90	−1.02 to 2.80
Age					0.07	−0.03 to 0.19	−0.08	−0.14 to −0.02^*	0.15	−0.01 to 0.32	−0.12	−0.22 to −0.03^*
Sexual orientation					0.30	−0.69 to 1.30	0.38	−0.68 to 1.44	0.07	−1.17 to 1.32	0.28	−0.83 to 1.39
Race/Ethnicity
Non-Hispanic white					—	—	—	—	—	—	—	—
Non-Hispanic black					−2.07	−4.51 to 0.36	−1.45	−3.00 to 0.08	−2.53	−5.31 to 0.23	−1.66	−3.28 to −0.04^*
Hispanic and others					0.23	−3.30 to 3.77	−0.14	−2.66 to 2.94	0.63	−4.30 to 5.56	−0.52	−3.60 to 2.57
Education
Below grade 12					—	—	—	—	—	—	—	—
Grade 12					−2.04	−3.87 to −0.21^*	−0.77	−1.95 to 0.42	−0.76	−3.19 to 1.68	0.23	−1.18 to 1.63
Above grade 12					−2.06	−4.46 to 0.35	−0.96	−2.43 to 0.51	−0.54	−3.28 to 2.20	0.45	−1.35 to 2.24
Income level
<$10,000 (years)					—	—	—	—	—	—	—	—
10,000 to 34,999 $ (years)					0.14	−1.97 to 2.25	−1.00	−2.41 to 0.41	−0.62	−3.30 to 1.99	−0.73	−2.45 to 0.99
≥35,000 $ (years)					−2.28	−4.38 to −0.18^*	−1.26	−2.51 to −0.01^*	−3.37	−6.25 to −0.49^*	−1.31	−2.78 to 0.16
Years of injection drug use									−0.03	−0.13 to 0.06	0.02	−0.045 to 0.08
Injection frequency, past 12 months
More than once a day									—	—	—	—
Once a day or less									−1.84	−4.67 to 0.98	−2.09	−3.49 to −0.69^*
Often used crack, past 12 months
Never									—	—	—	—
More than once a day									−1.52	−4.64 to 1.60	−1.20	−3.13 to 0.72
Once a week or less									−1.69	−4.63 to 1.24	−1.82	−3.77 to 0.11
Exchange sex in the past 12 months
No									—	—	—	—
Yes									0.84	−1.39 to 3.07	1.21	−0.15 to 2.58

p < 0.05, ^**p < 0.01, ^***p < 0.001.

†

Unadjusted model.

CI, confidence interval.

Discussion

This study examined the association between IPV victimization and psychological distress among men and women who inject drugs. We found that nearly one in 10 PWID in our study reported a history of physical or sexual IPV in the past year. IPV prevalence was 12% for women who injected drugs and 10% for men who injected drugs. The IPV prevalence in our study was similar to those reported in a previous study (Krahé et al. 2005). A review of the literature on IPV with a focus on gender differences revealed a prevalence of IPV that ranged from 4.1% to 19% for males and 2.7% to 22.7% for females (Krahé et al. 2005). While women who injected drugs in our study reported more IPV than men, some past research has suggested that men may underreport IPV out of fear of stigma (Astin et al. 2003). A recent study in Canada, for example, documented a similar prevalence of IPV in men and women (Ibrahim and Burczycka 2016). Some research has also suggested that IPV is overrepresented in men in substance use treatment (Stuart et al. 2009a,b). However, the gender differences in the level of IPV may depend on the context and setting (Shorey et al. 2017). Men with SUDs or men in substance use treatment may experience IPV differently than the general population of men.

The most common type of IPV experienced by PWID in this study differed by gender, with women who injected drugs more commonly experiencing sexual violence, and with men who injected drugs more commonly experiencing physical violence. This finding is consistent with some studies among men with opioid dependence (Krahé et al. 2005; Moore et al. 2011). Also, studies from the United Kingdom and Germany have found that males experience more physical IPV than females (18% vs. 13% and 6% vs. 2.7%, respectively; Krahé et al. 2005). However, this pattern has not been found in some other studies (Carbone-López et al. 2006; Coker et al. 2002). This discrepancy may be due to differences in the study population and settings, with general population studies (Carbone-López et al. 2006; Coker et al. 2002; Krahé et al. 2005) revealing a different pattern of gender differences compared with studies like ours that specifically focused on PWID.

The higher prevalence of sexual IPV among females who inject drugs could be explained by the fact that females who inject drugs are a vulnerable population whom others in higher social power (such as sexual partners, police or law enforcement) may sexually abuse (Joint United Nations Programme on HIV/AIDS 2018). This finding could be a function of unequal power between genders, especially among PWID who may have limited negotiating power over sex or decisions to leave a violent relationship. Gender inequality in power dynamics is a known phenomenon and may be exacerbated among women who inject drugs due to potential dependency on partners as providers of drugs and financial support in a context of very limited resources (Conroy 2014). In some cases, sex is exchanged for drugs or money, which may increase the risk of experiencing violence.

In this sample of PWID, the overall level of psychological distress was moderate. This finding is consistent with studies among PWID (Kinner et al. 2009; Waldrop-Valverde and Valverde 2005), and higher than what has been reported in the general U.S. population (Kessler et al. 2003a). The finding of a greater degree of psychological distress among women than among men is consistent with general population studies (Kessler et al. 2003a; Kinner et al. 2009; Waldrop-Valverde and Valverde 2005). National epidemiological studies in the United States and globally have documented higher prevalence of depression in women than in men (Kessler et al. 2003b, 2009), possibly on account of lower socioeconomic status (e.g., lower employment and pay), higher prevalence of trauma, including sexual harassment and rape, hormonal differences, higher levels of neuroticism, and a higher tendency to ruminate on stressors observed among women than among men (Albert 2015; McLean et al. 2011).

We also found that both men and women injection drug users with a history of IPV experienced more psychological distress than those without a history of IPV. This finding is consistent with previous studies (Bonomi et al. 2006; Campbell 2002; Carbone-López et al. 2006; Leiner et al. 2008; Sullivan et al. 2009 2012; Turner et al. 2020) {Jiwatram-Negrón, 2018 #73}. IPV may operate as a direct source of stress, or may be a proxy of life conditions and relational and contextual factors, which increase vulnerability to both IPV and distress.

Among PWID in our study, educational and income levels were not different among those who experienced psychological distress and among those who did not. However, the literature shows higher educational and income levels to be protective against IPV and psychological distress (Jordan et al. 2010; O'donnell et al. 2002; Orpana et al. 2009). This inconsistency may be related to differences in the studied populations. Another explanation for this finding is that in the—females who inject drugs—IPV is similarly experienced across all educational and income levels.

Also, among PWID in our study, non-Hispanic black respondents experienced less psychological distress than non-Hispanic white respondents. While some studies have shown no racial difference in psychological distress (Bratter and Eschbach 2005; Utsey et al. 2008), others have reported higher distress among white populations (Bratter and Eschbach 2005; Drapeau et al. 2012), and still other studies have shown higher distress among black populations (Lincoln and Chae 2010; Mossakowski 2008). The relationship between race and psychological distress among PWID is complex and warrants future study.

The links between SUDs, IPV, and psychological distress may be explained by the Tension Reduction Theory (Conger 1956) or self-medication hypothesis (Khantzian 2003). People who have experienced IPV may (mis)use drugs as a learned behavior to cope with the distress associated with their IPV and mental health problems because they expect that substance use will alleviate the negative physical and psychological sequelae of IPV (Jaquier et al. 2015). In this view, drug use is a coping mechanism for IPV and other types of trauma. Therefore, comprehensive integrated treatment is recommended to target comorbid psychological distress and drug use simultaneously within treatment and harm reduction programs, with service providers who coordinate care or provide mental health treatment as a team. It implies a program that not only addresses drug use, mental distress, and experiences of trauma, such as IPV directly, but also that provides services such as housing, employment, social services, and skill development that might indirectly impact health and wellbeing outcomes (Morisano et al. 2014). Neglecting to address the complexity and interrelationships of any of these challenges could enhance the likelihood of escalating drug use or relapse.

Although the present study provides important insights about the association of IPV and psychological distress among PWID as a marginalized population, the findings should be interpreted with consideration of three main limitations. First, the relationship between psychological distress and IPV in this study cannot be interpreted as causal, as the directionality of the association is unclear due to the study's cross-sectional design. Second, the use of self-report may have produced measurement bias, and men and women have different risks of underreporting IPV and psychological distress due to stigma, social desirability, gender expectations, or reprisal. Finally, our analysis is also not weighted to account for RDS, as the goal of the present study was to test a hypothesis about the relationship between IPV and psychological distress rather than estimate the population-level prevalence. Finally, we considered only physical and sexual violence in this study. Given the observed association between poor mental health and emotional violence in the general population, it is suggested that future studies should also be considered.

Conclusion

The present study introduces IPV as a potential contributing factor to the psychological distress experienced by women who inject drugs. Given the observed association between IPV and psychological distress, screening programs for IPV are recommended to help address the mental distress among PWID. Another potential strategy for successful mental health promotion among this population is use of a trauma-informed approach in the provision of services. Findings from the present study can help increase efforts to develop joint interventions that simultaneously prevent IPV and psychological distress among PWID. To understand the causal nature of these relationships, future research should longitudinally assess these intersecting experiences.

Footnotes

Acknowledgments

The authors wish to acknowledge the efforts of the Behavioral Surveillance Research (BESURE) Study team, and thank the study participants for their participation.

Author Disclosure Statement

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. All authors declared that they are not employees of any U.S.-sanctioned government and are submitting the article in their own personal professional capacity.

Funding Information

The National HIV Behavioral Surveillance System data collection in Baltimore was supported by contracts to The Johns Hopkins University from the Maryland Department of Health and by cooperative agreements between the Maryland Department of Health and the Centers for Disease Control and Prevention. The author(s) received no financial support for the research, authorship, and/or publication of this article.

Appendix

Appendix Table A1.

Information Collected as Part of Core Questionnaire, National HIV Behavioral Surveillance System

Measures	Content	Response choice
Demographics characteristics	Age, race/ethnicity, education, income, sexual orientation, employment status, history of homelessness in the past 30 days and in the past 12 months	Open-ended, multiple choice, dichotomous response
Sexual behaviors	Engaging in sexual relation in exchange for money, drugs, shelter, and so on in the past 12 months	Dichotomous response
Drug use	Age of initiating injection, Frequency of injection drug use in the past 12 months, Frequency of noninjection drugs use in the past 12 months	Open-ended response
Physical or sexual violence by an intimate partner	Slapped, punched, shoved, kicked, shaken physically hurt by a partner, and forced or pressured vaginal, oral, or anal sex by a partner.	Dichotomous response
Psychological distress	How often felt (1) nervous, (2) hopeless, (3) restless or fidgety, (4) sadness or so depressed that nothing could cheer you up, (5) that everything was an effort, and (6) feel down on yourself, no good or worthless, during the past 30 days	Five Likert response, including “all the time = 0, most of the ime = 1, some of the time = 2, a little of the time = 3, none of the time = 4”

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